According to Brino, as more employers are seeking to integrate workers’ comp into their benefit packages, a range of market trends and regulations may be responsible for slowing what could be a natural fit.

However, according to Derek Jones, an actuary with Milliman, more Americans getting insurance should actually mean a healthier workforce, and therefore fewer workers’ comp claims. Jones said that what is more significant is the potential shift of costs between the workers’ comp and health insurance markets.

The article states that the new expanded availability of health insurance could shift payments for injuries and illness otherwise covered by work comp to health plans. Yet, as Jones is quoted in the article, “To the extent any of these claims are larger, there may be a significant cost shift from workers’ compensation to healthcare”.

Brino then says that treatments typically covered by health plans may end up being covered by workers’ comp. This development has not gone unnoticed by members of the workers’ comp industry in the run-up to the passage and subsequent enactment of the Affordable Care Act (ACA). Many of them have predicted cost shifting will occur from health care to workers’ comp.

While finishing my MHA degree in 2011, I took an elective course on the PPACA, and the term paper I wrote for this course concerned the impact of the ACA on workers’ compensation. I found at the time that there were three types of impacts in the literature of the time. The first was Direct, the second was Indirect, and the third was Speculative.

While I did not specifically address the issue of cost shifting, I would have to classify this as a speculative impact, as we shall see, and as Brino’s article mentions.

And according to Steve Kokulak, a senior vice president of workers’ compensation and no-fault insurance at MagnaCare, and a long-time connection of mine on LinkedIn, “You’re going to see changes in both directions, and it’s probably too early to tell at this point.”

A bigger issue, Kokulak states, is the fact that more employers would like to have their workers’ comp, health and disability insurance benefits more integrated. Kokulak also stated that MagnaCare has seen an interest from both employers and their health plans “for a total product combining health, workers’ comp and disability.”

A major barrier to offering an integrated product, according to Brino, is not that large insurers need to acquire workers’ comp companies, but that the patchwork quilt of state laws that in many places prevent the use of narrow provider networks.

Many states, Brino writes, regulate whether carriers and employers can offer direct care for injured workers and have mandated workers’ comp fee schedules. Yet, the “biggest impediment” to the kind of integrated insurance some employers are seeking is “a matter of bringing a product to the marketplace and making sure it’s compliant with state workers’ compensation rules.”

Or better yet, state workers’ comp rules need to be brought into the 21st century, and not bound by what transpired last century. There also needs to be a release of the stranglehold that lawyers, doctors, and workers’ comp services providers have on the workers’ comp system, another point I have raised time and again in my articles.

It would be far more simple, Kokulak said, for self-insured employers, such as municipalities, large corporations and union-based employers. “It is just a matter of creating a program that would be legally compliant, and finding service partners, the TPAs and PPO networks,” Kokulak went on to say.

Finally, an open question for integrating health, disability and workers’ compensation, Kokulak said, is whether health plans are open to covering possible cost-shifting. “Will a health carrier be willing to absolve the cost of the additional two to five percent in claims, and how much would they raise the premiums?”

I am confident that some way or another, injured workers will be able to get medical care abroad through the medical tourism industry, if their employers, their insurance carriers, and others make it possible for them to do so. The naysayers who have attacked my idea as “ridiculous and a non-starter” have not been vindicated by Brino’s article. Rather, it is I who have been vindicated here, as some of the things he mentions, I have already discussed in past articles, and most specifically, rather strongly.

No one knows what the future of health care, let alone health insurance will look like, or where some people will get their medical care. There may be, like the current marketplace, many options out there, medical tourism being one of them. And if integration in some form is achieved, medical tourism would stand to gain significantly from that integration, and it will not matter how the payment is made, as long as the patient gets the best care possible at the lowest cost possible.

The only other impediment is what is between most people’s ears. My advice to them after reading this article is this: Be careful for what you DON’T wish for, you just might get that instead.

I received an invitation to connect on LinkedIn last Friday from Tucson Dunn, the CEO of Hanovera Healthcare International. After viewing his LinkedIn profile, I accepted his invitation. Prior to becomig CEO of Hanovera, Mr. Dunn was also the Chairman and CEO of the International Healthcare Commission (IHC) from June 2008 to June 2013.

Monday morning, I received an email from Mr. Dunn, introducing me to the International Healthcare Commission, and announcing that next month, the IHC will launch their “International Hospital Ratings” to identify hospitals that treat high numbers of foreign patients. Mr. Dunn also stated that this Award Mark will serve to attract more foreign patients to come to the top rated hospitals and cities.

According to Mr. Dunn, the Rating Criteria is simple and based on the annual volume of foreign patients treated (outpatient or inpatient) at the hospital. The ratings are listed below:

Over 1000 ― International Hospital rating
Over 5000 ― Distinguished International Hospital rating
Over 10,000 ― Outstanding International Hospital rating
Over 15,000 ― Premier International Hospital rating
Over 20,000 ― World Leading International Hospital rating

When I responded to his email, I asked him if this rating reflected actual medical tourists, i.e., those traveling from their home countries to a medical tourism destination, or does it include ex-pats living in those countries and getting medical care at those hospitals? I told him that many people engaged in the medical tourism industry have told me that most numbers are inflated with regard to actual medical tourists abroad.

In his follow up to my query, he said that was a very good question, and that it was the main topic of debate within the IHC for the past year. The final ruling, he said, leaned towards the Service Delivery itself. He also explained that if a hospital is treating vast numbers of international patients, then they know how to treat international patients, regardless of point of origin.

To summarize, he said, the award is not an indicator of inbound medical tourism, but rather a statement of capability based on performance. Same is true for Surgery Volume: If the hospital does 1000 CABGs in one year, then they probably know how to do CABGs. The Cardiac Surgery Award reflects the volume of Cardiac Surgery performed.

I responded that that will at least let those who are involved with inbound medical tourism, meaning both facilitators and patients, know which hospitals are the better ones in medical tourism destinations, based solely on the number of procedures performed at those hospitals. From those ratings, interested parties can probe deeper to find out just how good they are at performing those procedures, their success rates, outcomes, etc.

Mr. Dunn agreed, and then asked me to consider how many foreign patients come to the US for treatment per year. His reply stated that cost of those foreign patients was nearly US$5 billion worth. But as for which hospitals treat foreign patients, which hospitals have systems in place for large volumes, Mr. Dunn said, the IHC can help address those questions.

As an example, Mr. Dunn mentioned that the Medicover Hospital of Poland received a rating as a Distinguished International Hospital, based on the fact that they treated 8,614 foreign patients over the past twelve months. He went on to explain that if you were traveling as a tourist in Poland and needed a hospital, this award would be meaningful to you as a potential patient, since it would indicate that they have experience dealing with foreign patients, and that you would know that the staff could speak English.

About the International Healthcare Commission

The International Healthcare Commission is an independent healthcare ratings organization founded in 2009 in Atlanta, Georgia, and rates healthcare provider performance throughout the world. According to their website, the IHC is the Gold Standard for the international healthcare ratings industry. Likewise, they are the oldest, independent international healthcare performance ratings company. The IHC provides patients, referring physicians and payers with vital information they need when choosing an international healthcare provider.

The IHC supports hospitals, clinics and healthcare systems to achieve peak performance in international patient care. They help healthcare providers attract patient referrals. The IHC Rating Awards are recognized as Gold Seals of Approval, and they provide clear marks of distinction for performance, and they are evidence-based. The rating and award systems cover the following:

Foreign Patient Volumes
Surgical Procedure Volumes
Maternity Care

Their Mission

The International Healthcare Commission (IHC) works to guide patients and referring physicians to better healthcare providers. The IHC has been conducting healthcare market research in over 100 countries since 2009. IHC partners with hospitals, clinics, health systems and insurance companies to promote best-practice healthcare.

Their Ratings

International Hospital Ratings

There are five levels of International Hospital Ratings, and they identify hospitals that have dedicated systems, staff and resources for the care and treatment of foreign patients, as well as local patient communities.

International Hospital Rating

The IHC’s International Hospital Rating is the first rating level indicating that the hospital has achieved significant experience in the care and treatment of international patients. Hospitals achieving this level are rated and recognized as “International Hospitals” The criteria that determines this level is any hospital that treats over 1,000 foreign patients per year.

Distinguished International Hospital Rating

The IHC’s Distinguished International Hospital Rating is the second rating level indicating that the hospital has achieved substantial experience in the care and treatment of international patients. Hospitals achieving this level will be recognized and considered as “Distinguished International Hospitals”. The criteria that determines this level is any hospital that treats over 5,000 foreign patients per year.

Outstanding International Hospital Rating

The IHC’s Outstanding International Hospital Rating is the third rating level indicating that the hospital has achieved outstanding experience in the care and treatment of international patients. Hospitals achieving this level will be recognized and considered as “Outstanding International Hospitals”. The criteria that determines this level is any hospital that treats over 10,000 foreign patients per year.

Premier International Hospital Rating

The IHC’s second highest level of recognition is the Premier International Hospital Rating. This rating indicates that the hospital has achieved premier experience in the care and treatment of international patients. Hospitals achieving this level will be recognized and considered as “Premier International Hospitals”. The criteria that determines this level is any hospital that treats over 15,000 foreign patients per year.

World Leading International Hospital Rating

This is IHC’s highest rating for care and treatment of international patients. Only a few hospitals in the world ever achieve this level of experience and expertise. These elite hospitals are truly specialized in providing international care. Hospitals achieving this level are recognized and considered as “World Leading International Hospitals”. The criteria that determines this level is any hospital that treats over 20,000 foreign patients per year.

Surgery Excellence Ratings

IHC’s Surgery Excellence Ratings help patients, physicians and insurance companies identify surgical expertise and experience. Surgery Excellence Rating levels are based on annual number of surgical procedures within a surgical specialty area. These are the surgical specialty areas:

Cardiac Surgery

Eye Surgery

General Surgery

Gynecological Surgery

Neurosurgery

Oral and Maxillofacial Surgery

Orthopedic Surgery

Otolaryngology

Pediatric Surgery

Plastic Surgery

Surgical Oncology

Thoracic Surgery

Trauma Surgery

Urology

Vascular Surgery

There are three levels of Surgery Excellence Ratings:

International Surgical Excellence Rating

The IHC’s Surgery Excellence Rating indicates that the provider has achieved significant experience in the selected specialty surgical area. Organizations achieving this level are rated and recognized as “Excellent” in the surgical specialty. The criteria that determines this level are 300 to 499 surgeries in the specialty per year.

International Five-Star Surgery Rating

The IHC’s Five-Star Surgery Rating indicates that the provider has achieved outstanding experience in the selected specialty surgical area. Organizations achieving this level are rated and recognized as achieving “Five-Star” performance in the surgical specialty. The criteria that determines this level are 500 to 999 surgeries in the specialty per year.

International Center of Excellence Rating

The International Center of Excellence for Surgery Rating is the highest international rating available. This elite rating indicates the organization performed over 1,000 surgeries in the specialty area within one year.

International Clinic Ratings

Like the International Hospital Ratings, there are five International Clinic Ratings. IHC’s International Clinic Ratings identify stand-alone outpatient centers that have dedicated systems, staff and resources for care and treatment of foreign patients, as well as local patient communities. And like the International Hospital Ratings, foreign patients have unique language, customs and cultural needs that must be considered when providing care and treatment. The international patients want to know that their provider can accommodate these unique needs. One of the best indicators of this capability is experience in treating significant volume of foreign patients each year. This volume indicator serves as the basis of IHC’s International Clinic Rating.

International Clinic Rating

The IHC’s International Clinic Rating is the first rating level indicating that the ambulatory care center has achieved significant experience in the care and treatment of international outpatient patients. Clinics achieving this level are rated and recognized as “International Clinics”. The criteria that determines this level is any clinic that treats over 1,000 foreign patients per year.

Distinguished International Clinic Rating

The IHC’s Distinguished International Clinic Rating is the second rating level indicating that the clinic has achieved substantial experience in the care and treatment of international patients. Clinics achieving this level will be recognized and considered as “Distinguished International Clinics”. The criteria that determines this level is any clinic that treats over 5,000 foreign patients per year.

Outstanding International Clinic Rating

The IHC’s Outstanding International Clinic Rating is the third rating level indicating that the clinic has achieved outstanding experience in the care and treatment of international patients. Clinics achieving this level will be recognized and considered as “Outstanding International Clinics”. The criteria that determines this level is any clinic that treats over 10,000 foreign patients per year.

Premier International Clinic Rating

The IHC’s second highest level of recognition is Premier International Clinic Rating. This rating indicates that the ambulatory care center has achieved premier experience in the care and treatment of international patients. Stand-alone clinics achieving this level will be recognized and considered as “Premier International Clinics”. The criteria that determines this level is any clinic that treats over 15,000 foreign patients per year.

World Leading International Clinic Rating

This is IHC’s highest rating for care and treatment of international patients. Only a few ambulatory care centers in the world ever achieve this level of experience and expertise. These elite clinics are truly specialized in providing international care. Clinics achieving this level are recognized and considered as “World Leading International Clinics”. The criteria that determines this level is any clinic that treats over 20,000 foreign patients per year.

What this means

Naturally, judging any enterprise by the volume of work performed does not necessarily tell us a lot about how well they perform that work. And knowing how many foreign patients a hospital treats per year does not tell us if these patients are real medical tourists, i.e., traveling from their home country to a medical tourism destination hospital, or are ex-patriots living in that particular country and getting medical care in a foreign hospital. This was the question I posed to Mr. Dunn earlier this week.

If that was the case, McDonalds would be a great company that serves the best hamburgers in the world, based solely on the billions of hamburgers sold, and on how many restaurants they have around the world.

What is missing from these ratings is quality of care, outcome measures, success rates of surgeries, and a host of other vital data which can tell a patient, their referring physician, their employer or their employer’s insurance company, that the foreign hospital and foreign physicians are just as good as or better than what is available locally.

Also missing from these ratings are the level of expertise of the physicians and nurses, and the professionalism and attention to detail that determines patient care. And finally, knowing whether or not the hospital or clinic has the latest technology and proficiency to use that technology is crucial to ascertain the true level of excellence of any hospital or clinic.

In many of my previous posts, the issue of transparency has come up, and generally I have written that the medical tourism industry needs to become more transparent on issues of price and quality, because that is the main selling point the industry makes to its customers and potential customers. Whether such transparency comes from the industry itself, or from outside, independent organizations like the International Healthcare Commission.

Like any other product or service, health care has its many rankings and ratings, but taken together, ratings from the IHC, JCI, NCQA, ISQua and other accreditation organizations, may be able to tell individuals, employers, and carriers that these facilities have obtained a baseline of care and expertise. More data is needed before medical tourism can be taken seriously as an alternative to high price and substandard medical care, but until that happens, this organization may be a step in the right direction.

The chart from the 2013 State of the Line Report, which appears below, indicated that the average medical cost for lost-time claims in 2012, was $28,500, and was a preliminary figure (based on data valued as of 12/31/2012). The revised figure for 2012 in this year’s report (see Chart 2), was $27,900, a slight decrease. However, the preliminary figure for the average medical cost for 2013 in this year’s report, was $28,800 (based on data valued as of 12/31/13), an increase of $300, which does not seem like much, but still a sign that costs are going up, not down, if only slightly.

That brings me to the dialogue I used last year to highlight that costs are still rising:

Doctor: “Good news, Mr. Jones. We’ve managed to slow the progression of your disease.” Mr. Jones “What’s so good about that? I’m still dying, only slower.”

Chart 1 ― Avg. Medical Cost per Lost-time Claim As of May 2013

The glaring difference between the two charts is that four years have been knocked off from this year’s chart, and begins at 1995, instead of 1991, as above. Last year’s State of the Line Report showed the Annual Change from selected years as follows:

This year’s report showed that the Annual Change 1995―2012 was +6.7%. While the annual percentage change dropped from its high of 10.6% in 1999, the annual percentage change held the same from 2012 to 2013, at 3%. Yet, the trendlines in both charts shows that medical costs are still trending upwards.

Chart 2 ― Avg. Medical Claim Cost per Lost-time Claim As of May 2014

When I cited the State of the Line Reports in my White Paper and last year’s post, I was unable to determine if these figures included claims that had surgeries, because the figures seemed a little low for claims that had surgical procedures attached to them. However, this year, I contacted NCCI, and received a response today from Juan Restrepo, Research Consultant at NCCI in Boca Raton.

He told me that the medical severity presented is derived from reported losses from all claims involving lost-time. Those losses and claims are subsequently developed to ultimate and serve as the basis for the aggregates presented. Medical-only losses are specifically excluded. The only added caveat is that the metric represents an aggregate for the states where NCCI provides ratemaking services (currently 37), including state funds and excludes WV. In addition, the data excludes high deductible policies, so the true cost of medical care is probably far higher than reported.

In Indiana, hospital payments were among the highest at nearly $12,000 per 2010 claim, evaluated in 2012. This was attributed to higher prices and inpatient payments. Overall, medical payments per workers’ compensation claim in Indiana grew 8% per year; on average, from 2006 to 2001, faster than in any other state.

That medical costs in workers’ comp and health care in general are rising is not in doubt. What is in doubt is what to do to solve this problem. The workers’ compensation industry goes on about more cost containment strategies, more legislation and more regulation, and more attempts to reform a broken and dysfunctional system.

According to Lynch, the health care industry has dwarfed any advancement that has been developed in the workers’ comp industry. He went on to add that the Property & Casualty (P/C) industry is very slow to innovate and lags behind other industries, including other parts of the insurance industry, and the workers’ comp industry is way behind and must catch up.

While much of what Lynch had to say related to technology and innovation of that technology, the same can be said for other aspects of innovation that the health care industry is pursuing, such as medical tourism. The workers’ comp industry needs to seriously look at what it has done for decades and that has not worked, and then decide that the health care industry, particularly the medical tourism industry can offer an alternative to doing the same thing over and over again and expecting different results.

Yes, it is difficult. Yes, there are barriers and obstacles. And yes, there are certifications and accreditations, and licensing and all the other legal roadblocks that have been erected to prevent other medical providers from handling workers’ comp claims, but when you stand back and look at the bigger picture and see that when one person injures themselves on the job and another is injured riding a horse, and both injure the same body part, the surgery is the same, the surgeon can even be the same, but one patient can only be treated if the physician has jumped through all the hoops required by workers comp, and the other can go ahead and treat the patient without going through those same hoops. Of course, the physician has to have a license to perform medicine, and what does it matter if he got trained at Harvard Medical School or trained in a well-known medical school in his home country or region? Is the teaching of medicine any different? Are American patients somehow different than Latin Americans, Asians, or Europeans? Or, is the reality that once the scalpel goes in, we are all the same and look the same when the blood starts flowing? Listening to the so-called “workers’ comp experts” one would have to say no, but I know otherwise.

I don’t have all the answers, but like Robert Goddard, the father of modern rocketry, or the first person to say that it was possible to split the atom, I have the idea to do it. Neither men were there when we landed men on the moon or dropped the first atomic bomb on Hiroshima. Yet, Goddard and the man who thought it was possible to split the atom gave others, like Werner von Braun and Robert Oppenheimer, the idea that we could. Those feats were certainly more difficult and more perilous than opening up a man-made, medical-legal system to an alternative that offers lower cost and better quality health care. Or are we content to let working people suffer the indignity of a broken and dysfunctional system just to placate doctors, lawyers and other service providers?

For the past two days, I attended the Medical Travel International Business Summit in Miami Beach. The summit was organized by ProMed, which is the Council for International Promotion of Costa Rica Medicine.

While the summit was much smaller than the 5th World Tourism and Global Health Care Congress that I attended in October 2012, nonetheless, it was informative and allowed me to finally meet a few of the people I have connected with on LinkedIn, and who have read my blog.

The first person I met on Wednesday was the woman who assisted a woman named Joy Guion, whose employer, HSM Solutions, I discussed in my post, US Companies Look to ‘Medical Tourism’ To Cut Costs. Maria Segovia is the Operations Manager for Medical Tours Costa Rica. Her company shared a booth with a company called GoEasy, a transportation company that was featured in the ABC report, and the Hotel Bougainvillea, a hotel in San Jose, Costa Rica. Maria told me about the CEO of another company, Rajesh Rao, who helped HSM send Joy and other HSM employees and their families for medical care in Costa Rica.

I spoke to Mr. Rao this morning after he gave a presentation entitled: Global Health Options: A Success Story in the US Employer Market. His company, IndUShealth, is based in Raleigh, NC and was founded in 2005. They signed their first employer client one year later, in 2006, and began serving HSM Solutions in 2008.

IndUShealth is now the leading corporate medical travel program administrator in the US, and provides comprehensive medical travel administrative solutions to self-funded employers. Their staff consists of a Medical Director and experienced Nurse Case Managers. The offer wide range of surgical procedures from bariatric surgery to several orthopedic procedures, and their partners in Costa Rica are the three companies I mentioned above, and the Clinica Biblica Hospital in San Jose.

On Wednesday, I also met, spoke to and attended the presentation of William Lacy, the President and CEO of the Association for Corporate Health Risk Management, or ACHRM. His booth was way in the corner in the back of the exhibit hall (figures they’d stick Risk Management people in a corner), and I introduced myself and told him about my background and we have some things in common that might lead to something down the road. During his presentation, he discussed why medical tourism should pursue self-funded employers. He cited a rapidly changing health care delivery model and that self-funded employers are a growing trend.

Two other individuals I met there yesterday were a husband and wife who I connected with on LinkedIn back in 2012, before I even attended the MTA Congress in October of that year. Their company, Custom Assurance Placements, Ltd., (CAP) is is a wholesale insurance broker in Columbia, SC. They provide excess and surplus lines as well as admitted markets for retail insurance agencies. They also create and manage custom programs needed for a selected risk or exposure group.

According to the LinkedIn profile of the President, Tracy Simons, CAP has markets for long haul trucking, coastal property, commercial auto, workers compensation, coastal homeowners, pollution liability, non-profit organizations, international travel insurance, foreign package policies and more. In addition, they have developed a medical travel accident product for medical travelers or medical tourists which covers complications and accidents called Global Protective Solutions. They also provide liability for employers and facilitators involved in medical tourism. Tracy has spoken on risk management for medical tourism or medical travel in several countries and cities around the world including Brazil, Costa Rica, Colombia, Monaco, Spain, New York and Las Vegas.

I specifically wanted to mention these companies for a very good reason. There are a number of individuals in the workers’ compensation industry who poo-poo the idea of medical tourism in workers’ comp, whether it is for fully insured employers or for self-funded employers. While both the ACHRM and IndUShealth have worked with self-funded employers on the health care side to offer medical tourism as an option, there are companies and employer organizations out there who would probably be able to accommodate the workers’ comp industry in doing so, if they only realized that they are wasting far too much money chasing after fee schedules, negotiated prices that are still higher than what medical tourism can offer, or the favorite cost reduction program de jure. And with a company like Custom Assurance and their Global Protective Solutions company, the issue of liability and other issues can be addressed to the satisfaction of not only employers, but to carriers and medical tourism facilitators.

While going through my email, I found an article from the Workers’ Comp Insider blog’s Health Wonk Review. An article they featured from Insurance Journal, entitled 10 Challenges Ahead for Workers’ Compensation, by Andrea Wells, discussed some of the challenges that lie ahead for workers’ compensation. One area she mention was technology and innovation. Ms. Wells quoted Thomas Ryan, the CEO of Lynch Ryan & Associates, the publisher of the Workers’ Comp Insider blog , as saying the following: “When it comes to technological innovations, the health care industry’s advancements dwarf anything that’s developed in the workers’ comp industry for years.” The P/C insurance industry, Ryan says, “is very slow to innovate and is lagging behind other industries, as well as other parts of the insurance industry, in adoption and rapid movement to technology usage and innovation,” and goes on to say that “the workers’ comp industry is way behind and it must catch up.”

This is also true for the implementation of medical tourism into workers’ comp. Yes, there are barriers. Yes, there are those who benefit from and defend the broken dysfunctional system. Yes, there are others, who while calling for change, attack and criticize the very change that the health care side is looking at and that employers like HSM are offering to their employees as an option. Yes, there are politicians who get paid off by doctors, hospitals, and the other service providers to write workers’ comp rules and regulations that limit choice of medical provider and only protect the bottom-line of attorneys, doctors, hospitals and service providers. And yes, there are those, whose blind super-patriotism, egos, prejudices and knee-jerk reactions are holding back millions of injured American workers, both native-born and immigrants, from getting better medical care at lower cost, simply because they or their friends in the workers’ comp industry have a vested interest in keeping the status quo or with the increasing Latinization of the American workforce are willing to let them get sub-standard, expensive and sometimes needless treatment in the name of making a buck off of their pain and suffering.

We aren’t the best when it comes to providing health care, and there are pages and pages of data to support this and other problems we have in health care, but burying your head in the sand (or some other place) will not solve them. We need to look elsewhere, and countries like Costa Rica are providing the means and the resources to do so. The only thing lacking is the will to do it, and to swallow our stupid, vain, egocentric, super-patriotic, all-American, bullet-headed pride.

Quotes

“Impossible is just a big word thrown around by small men who find it easier to live in the world they’ve been given than to explore the power they have to change it. Impossible is not a fact. It’s an opinion. Impossible is not a declaration. It’s a dare. Impossible is potential. Impossible is temporary. Impossible is nothing.”

– Muhammad Ali

“If people are not laughing at your goals, your goals are too small..”

– Azim Premji

“Those who say your dreams are ridiculous have given up on theirs.”

– Unknown

Permanence, perseverance and persistence in spite of all obstacles, discouragements, and impossibilities: It is this, that in all things distinguishes the strong soul from the weak.

– Thomas Carlyle

“As the work is done for the employer, and therefore ultimately for the public, it is a bitter injustice that it should be the wage-worker himself and his wife and children who bear the whole penalty.”

– President Theodore Roosevelt, 1907

To permit every lawless capitalist, every law-defying corporation, to take any action, no matter how iniquitous, in the effort to secure an improper profit and to build up privilege, would be ruinous to the Republic and would mark the abandonment of the effort to secure in the industrial world the spirit of democratic fair dealing.

– Theodore Roosevelt, 1908

“The modern conservative is engaged in one of man’s oldest exercises in moral philosophy; that is, the search for a superior moral justification for selfishness.”

– John Kenneth Galbraith

“Only a fool would try to deprive working men and women of their right to join the union of their choice.”

– Dwight D. Eisenhower

“I hope we shall crush in its birth the aristocracy of our monied corporations which dare already to challenge our government to a trial by strength, and bid defiance to the laws of our country.”

– Thomas Jefferson

“Mischief springs from the power which the moneyed interest derives from a paper currency which they are able to control, from the multitude of corporations with exclusive privileges… which are employed altogether for their benefit.”

– Andrew Jackson

“I see in the near future a crisis approaching that unnerves me and causes me to tremble for the safety of my country. Corporations have been enthroned, an era of corruption in high places will follow, and the money-power of the country will endeavor to prolong it’s reign by working upon the prejudices of the people until the wealth is aggregated in a few hands and the Republic is destroyed.”

– Abraham Lincoln

“Do not go where the path may lead; go instead where there is no path and leave a trail”

– Ralph Waldo Emerson

“Some men see things as they are and say why. I dream things that never were and say why not.”

“Capital is reckless of the health or length of life of the laborer, unless under compulsion from society.”

– Karl Marx

“The secret of change is to focus all of your energy, NOT on fighting the old, but on BUILDING the NEW.”

– Socrates

“Every man takes the limits of his field of vision for the limits of the world”

– Arthur Schopenhauer

“All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.”

– Arthur Schopenhauer

“You have enemies? Good. That means you’ve stood up for something, sometime in your life.”

– Winston Churchill

“No matter what people tell you, words and ideas can change the world.”

– Robin Williams

“There can be no equality or opportunity if men and women and children be not shielded in their lives from the consequences of great industrial and social processes which they cannot alter, control, or singly cope with.”

– Woodrow Wilson

“Although it is not true that all conservatives are stupid people, it is true that most stupid people are conservative.”

– John Stuart Mill

“The masters of the government of the United States are the combined capitalists and manufacturers of the United States.”

– Woodrow Wilson

“The test of our progress is not whether we add more to the abundance of those who have much it is whether we provide enough for those who have little.”

– Franklin D. Roosevelt

“Of all the forms of inequality, injustice in health [care] is the most shocking and inhuman[e]…”